8383 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BUILDING PROJECT IDENTIFICATION PERMIT NUMBER
Be-di-DING
& PERMIT /� /�
ADDRESS Q )8 3
I / 02 60 so. De A4zm SIVA. BUILDING-ELECTRICAL-PLUMBING -MECHANICAL Q J
OWNER'S PLAN CHECK VALIDATION
NAME QTY. ELECTRIC PERMIT FEE
Wells Fa•yo ONE 27 - 629
CONTRACTORS
NAME OUTLETS-SWITCHES-RECEP 10.00/1.00
N
M/4" r e e Sl h J LIC NO 2 4 g7f 6 LIGHTING FIXTURES 10.00/1.00
CONTRACTOR ORs
COND51uFKf an p APPLIANCES-RESIDENTIAL 4.00
12 POP,
q)
33 6. POP, M S* PHONE {Q/ PANELS 10.00 DATE OF APPLICATION
ARCHITECT PANELS (OVER 200 AMP) 20.00 PLAN CHECK FEE P.C.NO.
OR
ENGINEER C efgV Col,5 f (/&),No
36 3 0 SIGNS TRANS. 3.00
ARCH.OR END SPECIAL CIRCUIT SQQ PERM IT VALIDATION
ADDRESS ft otST o n ,
/Q 3 3 E . Rona Id f f, ZIP 9110 g rrEMP.METER OR POLE INS. 20.00
APPLICANT s MOTORS SEE FEE SCH.
ADDRESS
f2 i? (. ROnmlf/ S+, Sfkn . %St°g SERVICE CHANGE 20.00
w 0 o LICENSFI)CON'I'RACTORS DECLARATION TEMP.POLE 30.00 /L�
¢ v I hereby affirm that 1 am licensed under provisions of Chapter 9 ISSUANCE GATE
H < m (commencing with Section 7000)of Division 3 of the Business and BLDG. ELECT. PLG. MECH.
r m z Professions Code,and my license Is in full force and effect.
z o w License Class C.1 Op Lies.Nwnber��-� �6 ❑ ❑ El ❑ -
9 F 0 Date Contractor
a Y 5 BUILDING PERMIT
¢ ce u OWNER-BUILDER DECLARATION
w3 LL m 1 hereby affnm that I am exempt from the Contranor's License MISC.- REFER TO ORD INFORMATION
u0 ¢ Law for the following reason.(Sec.7031.5.Baslnessand Professions PERMIT ISSUANCE 10.00 vAwnnoN S/FT.
m I Code:Any city or county which requiresa permit to construct,alter,
ac ¢ Q. improve,demolish,or repair any structure,prior to its issuance,also ELEC.CONTR. UC.NO. ELEC. 2)000 . 00 +
D ¢ requires the applicant for such permit to file a signed statement that TOTAL PERMIT TO
w'm" he is licensed pursuant to the provisions of the Contractor's License
r z i LAW(Chapter 9(ecmmenciogwith Section 7000)of Division 3 ofthe -
¢ Business and Professions Code)or that he is exempt therefrom andOTV. PLUMBING PERMIT FEE SU
_� xo
tt F o the basis for the alleged exemption.Any violation of Sect ion 7031.5 STORIES TYPE CONSTR.
dam by any applicant for a permit subjects the applicant to a civil penalty ALTER-DRAIN& VENT-WATER (EA.) 5.00
of not more than five hundred dollars(SS00).):
❑ 1,as owner of the property,or my employees with wages as BACK FLOW PROTECT.DEVICE 4.00 OCC.GROUP RES.UNITS
their sole compensation,will do the work,and the structure is not
intended or offered for sale (Sec. 7044, Business and Professions DRAINS-FLOOR,ROOF,AREA,COND. 5.00
Code:The Contractor's License Law does not apply to an owner of
property who builds or improves thereon,and who does such work F IXTUR ES-PER TRAP 5.00 So.FT,FLOOR AREA TOTAL ACREAGE
himself or through his own employees.provided that such improve.
meets are not intended or offered for sale.If,however,the budding GAS-EA.SYSTEM-I IINC.4 OUTLETS 6.00
or improvement is sold within one year of completion,the owner- GAS-EA.SYSTEM-OVER 4 (EA.) 2.00 BUILDING USE ..a.
builder will have the burden of proving that he did not build or ice- RES IND CON PB Omer
prove for purpose of sale.). INDUSTRIAL WASTE INTER. 30.00
❑ 1,as owner of the property,am exclusively contracting with
licensed contractors to construct the project(Sec.7044,Business LAWN SPRINKLERS- 1 INC 5 V.B. 6.00 ASSESSORS PARCEL NO.
and Professions Code:The Contractors License Law does not apply
to an owner of property who builds or improves thereon,and who LAWN SPRINKLERS-OVER 5(EA.) 1.00
contracts for such projects with a Nncactorls)licensed pursuant to
the Contractor's license Law. SEWER-SANITARY-STORM EA.200ft/10.00 TRACT NO. PARCEL NO.
❑ l am exempt under Sec.�,B.&P.C.for this WATER HEATER W/VENT 6.00
ocalm
Owner Date WATER SYSTEM 5.00 ACC.DATE ACC.FILE No.
WORKF.RS'COSIPENSATION DECLARATION WATER TREATING EQUIP. 5.00
I hereby affirm that I have a certificate of consent to self-insure - ZONING ENG.SITE NO.
x. or a certificate of Workers'Compensation Insurance,or a certified
copy th rcof(Sec 3800.Lab.C.). -
PDIi y �nYt7_t(/g Ci T r y^ Il 6 F n S
O ❑ Cert filled copy Is hereby fur i t FIRE SPRINK ENERGY T-24
Z Z 4• Certified copy is filed with� 0' tlatcity inspection division. MISC.- REFER TO ORD. N
O Applicant j 4G i e y V N V
t ♦- N PERMIT ISSUANCE . 10.00
-LU CERTIPo OMOP EXEMPTIONNINS FROM WORKERS' FLOOD ZONE aL,y-c.
W COMPENSATION INSURANCE PLG.CONTR. LIQ NO. PLG. V❑ N❑ Y ❑ N❑
= Z (This section need not be completed if the permit is for one TOTAL
hundred dollars(S 100)or less J
U O 1 certify that in the performance of the work for which this pe 1 OTY. MECHANICAL PERMIT FEE FEE SUMMARY
LL F mit is issued,I shall not employ any, perso ny manner so as to
U become subject to the Workers'Co. t Ion Laws of CLIROrnla.
ED Date Applicant ALTER OR ADD TO MECH. 5.00 BUILDING ,� S V
} w NOTICE TO APPLIC t,after making this Certificate of Ex-
H Z eruption,yo ecome subject to the Workers'Compensation APPLIANCE 5.00 PLAN CHECK
Prov" of the Labor Code, you must forthwith comply with /3
I provisions or this permit shall be deemed revoked. AIR HANDLING UNIT(TO 10=C.F.M.) 4.00 FEE a
CONSTRUCT ION LENDING AGENCY AIR HANDLING UNIT(OVER 10=C.F.M.) 6.00 • SEISMIC FEE 3--0
I hereby affirm that there is a construction lending agency lin EXHAUST HOOD (WITH DUCT) 5.00
the performance of the work for which this pe fit is issncd(Sec. MICROFILM
3097,Civ.C.), HEATING UNIT (TO 100,000 B.T.U.) 8.00
Lender's Name --
Lender's Address HEATI NG UN IT MOVER 100,000 B.T.U.)9.50 ELECTRIC
I certify that 11 tread ihiS applicwion and state thut'the above VENTILATION FAN (SINGLE) 4.00
information is correct. I agree to,comply with all city and county PLUMBING
ordinances and state lows relating to building construction, and BOILER-COMP(3 H.P.or 100,000 B.T.U.) 6.00
hereby aulhori e representatives of this city to enter upon the BOILER-COMP (Over 100,0o0BTU)SEE FEESCH. MECHANICAL
above-mentioned property for inspection purposes.
(we) agree to save, indemnify and keep harinless the City of MISC.- REFER TO ORD.
Cupertino against liabilities,judgments, costs and expenses which PERMIT ISSUANCE 10.00 CONST.TAX
may in any way ac cine against said City in cotsequcnce of the
granting of this permit MECH.CONT. LIC.NO. MECH.
c^. C.o.v� y / �g f TOTAL TOTAL 1 `
1� Signaturcof A4lplbont/Contractor �Date
INSPECTOR COPY ^s'
a